Wiki INSURANCE CLAIMS NOT PAID

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Pkirsch1

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Bristol, CT
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Hi,

We have an insurance carrier that is a religious cost share. They still owe us from over a year ago. Every time we call they say the same thing; "we have been updating our software, we apologize for the delay". They did give us claim #'s (Need #'s). My question is, can we bill the patient because their insurance or cost share has not paid us?

Thank you!
 
My advice is to check the patient's ID card. Many of those types of cost share plans are NOT insurance and do NOT meet the ACA definition of insurance.
It is possible it is not against your contract with the network to bill the patient in this situation. In fact, some of the religious cost share plans (ie Liberty HealthShare) do NOT use a network, therefore you have no contract. Regarding the surprise bill laws, I'm not sure that applies in this scenario, but it is a consideration. If the bill is from a year ago, the federal No Surprises Act requirement of an estimate prior to services would not have applied then.
Even if you cannot bill the patient, I would try at least involving the patient since they are the ones paying this cost share company every month thinking their bills are being paid.
There are many practices that do not accept assignment on these types of plans, particularly if there is no network contract. Patients are required to pay when services are rendered and are given a bill that they can submit and wait for their cost share to get around to pay them back.
 
Last edited:
csperoni said:
My advice is to check the patient's ID card. Many of those types of cost share plans are NOT insurance and do NOT meet the ACA definition of insurance.
It is possible it is not against your contract with the network to bill the patient in this situation. In fact, some of the religious cost share plans (ie Liberty HealthShare) do NOT use a network, therefore you have no contract. Regarding the surprise bill laws, I'm not sure that applies in this scenario, but it is a consideration. If the bill is from a year ago, the federal No Surprises Act requirement of an estimate prior to services would not have applied then.
Even if you cannot bill the patient, I would try at least involving the patient since they are the ones paying this cost share company every month thinking their bills are being paid.
There are many practices that do not accept assignment on these types of plans, particularly if there is no network contract. Patients are required to pay when services are rendered and are given a bill that they can submit and wait for their cost share to get around to pay them back.
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I agree.

In my experience, those types of plans usually aren't actual insurance. I would at least get the patient involved so that they are aware that their bill hasn't been paid.
 
mnmd9488 said:
I could be wrong but this sounds like it would be considered balance billing, which is a no-no . I believe you would only be able to bill co-payment.

I see that your location says CT so I looked up the Surprise Law for your state. Hope this helps!

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Thanks so much for your help!
 
csperoni said:
My advice is to check the patient's ID card. Many of those types of cost share plans are NOT insurance and do NOT meet the ACA definition of insurance.
It is possible it is not against your contract with the network to bill the patient in this situation. In fact, some of the religious cost share plans (ie Liberty HealthShare) do NOT use a network, therefore you have no contract. Regarding the surprise bill laws, I'm not sure that applies in this scenario, but it is a consideration. If the bill is from a year ago, the federal No Surprises Act requirement of an estimate prior to services would not have applied then.
Even if you cannot bill the patient, I would try at least involving the patient since they are the ones paying this cost share company every month thinking their bills are being paid.
There are many practices that do not accept assignment on these types of plans, particularly if there is no network contract. Patients are required to pay when services are rendered and are given a bill that they can submit and wait for their cost share to get around to pay them back.
Click to expand...
This is very helpful! Thank you!
 
If you are billing for outpatient mental health, most religious plans do not cover mental health in an outpatient setting. Are you contracted with that payer/network associated with the payer? If you are not contracted with that payer/network, you can either get the patient involved since they are supporting the payer with their premium payment and are contracted with the cost share payer, or bill the patient directly and let them fight it out with the payer.
 
I agree with Susan & Christine. In practices I have worked those were never accepted "plans" and it was self-pay. The patient could file their own claims. It's not the same thing as insurance. Also, these patients know how it works and shouldn't be suprised when they have to file their own claims. I would still cal the patient and let them know you are going to bill them even if it was that long ago in this case. They know they should have paid.

Examples:

What is Liberty HealthShare? We are not insurance. ​

Is Medi-Share Christian insurance?
No. Medi-Share is not insurance.
Christian Care Ministry and the Medi-Share program are not registered or licensed by any insurance entity, nor are we required to be.
 
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